Many in Congress think the government needs to set stricter rules to prevent health insurers’ from slow-walking decisions on whether to approve treatments. But representatives hit a snag last year after their bill to tighten up the “prior authorization” process breezed through the House because senators were concerned about the measure’s projected $16 billion cost. So they’re urging the Centers for Medicare and Medicaid Services to use its power over insurers to tighten up the rules around prior authorization. How so? More than 230 representatives and 61 senators wrote today to Health and Human Services Secretary Xavier Becerra and CMS Administrator Chiquita Brooks-LaSure asking them to make changes to a rule CMS proposed in December that would require health insurance companies to modernize the way they process treatment-authorization requests from providers. “The proposed CMS rules make huge strides forward for seniors,” Rep. Suzan DelBene (D-Wash.), the lead author of the letter and sponsor of last year's bill, told POLITICO. “But we think it needs to go further.” The lawmakers are calling on CMS to add several provisions to the regulation to align it more with the legislation, including: — Real-time prior authorization for routine matters — A 24-hour deadline for Medicare Advantage plans to answer prior authorization requests for “urgently needed care” — More detailed transparency metrics Why it matters: Insurers require health care providers to get their approval before conducting certain treatments. Their aim is to control costs, but ensuing delays in care can put patients at risk. A lack of standards among insurers can hamper the process. CMS’ December proposal would require Medicare Advantage plans and other public payers, such as those managing state Medicaid plans, to implement an electronic process for approving treatments. The regulation was expected to be less expensive for the government than the legislation the House passed last year. “The CBO score was an unfortunate roadblock last Congress, especially in the Senate. We shouldn’t let a CBO score get in the way of helping seniors access the care they are already entitled to under Medicare,” DelBene told POLITICO. “The hope is that once the rule is finalized and we get quality policy in place, hopefully with the real-time decision-making and faster response deadlines components, it will also bring the score down.” What’s next? CMS has set a December 2025 date for finalizing its rule but says it will publish it sooner if it can.
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